Preventing vincristine administration errors: Does evidence support minibag infusions?

Although vincristine sulfate is indicated for IV use only, it has been inadvertently administered intrathecally. Accidental vincristine administration via the spinal route (intrathecally via a lumbar puncture or intraventricularly via an Ommaya reservoir) causes rapid sensory and motor dysfunction, usually followed by encephalopathy, coma, and death (Schulmeister, 2004). Autopsy findings include grossly edematous and congested brain and spinal cord tissue, with axonal degeneration and myelin loss of the spinal nerves (Kwack et al., 1999; Williams et al., 1983).